library/parse_era.inc.php

   1 <?php
   2   // Copyright (C) 2006 Rod Roark <rod@sunsetsystems.com>
   3   //
   4   // This program is free software; you can redistribute it and/or
   5   // modify it under the terms of the GNU General Public License
   6   // as published by the Free Software Foundation; either version 2
   7   // of the License, or (at your option) any later version.
   8
   9 function parse_era_2100(&$out, $cb) {
  10     if ($out['loopid'] == '2110' || $out['loopid'] == '2100') {
  11
  12         // Production date is posted with adjustments, so make sure it exists.
  13         if (!$out['production_date']) $out['production_date'] = $out['check_date'];
  14
  15         // Force the sum of service payments to equal the claim payment
  16         // amount, and the sum of service adjustments to equal the CLP's
  17         // (charged amount - paid amount - patient responsibility amount).
  18         // This may result from claim-level adjustments, and in this case the
  19         // first SVC item that we stored was a 'Claim' type.  It also may result
  20         // from poorly reported payment reversals, in which case we may need to
  21         // create the 'Claim' service type here.
  22         //
  23         $paytotal = $out['amount_approved'];
  24         $adjtotal = $out['amount_charged'] - $out['amount_approved'] - $out['amount_patient'];
  25         foreach ($out['svc'] as $svc) {
  26             $paytotal -= $svc['paid'];
  27             foreach ($svc['adj'] as $adj) {
  28                 if ($adj['group_code'] != 'PR') $adjtotal -= $adj['amount'];
  29             }
  30         }
  31         $paytotal = round($paytotal, 2);
  32         $adjtotal = round($adjtotal, 2);
  33         if ($paytotal != 0 || $adjtotal != 0) {
  34             if ($out['svc'][0]['code'] != 'Claim') {
  35                 array_unshift($out['svc'], array());
  36                 $out['svc'][0]['code'] = 'Claim';
  37                 $out['svc'][0]['mod']  = '';
  38                 $out['svc'][0]['chg']  = '0';
  39                 $out['svc'][0]['paid'] = '0';
  40                 $out['svc'][0]['adj']  = array();
  41                 $out['warnings'] .= "Procedure 'Claim' is inserted artificially to " .
  42                     "force claim balancing.\n";
  43             }
  44             $out['svc'][0]['paid'] += $paytotal;
  45             if ($adjtotal) {
  46                 $j = count($out['svc'][0]['adj']);
  47                 $out['svc'][0]['adj'][$j] = array();
  48                 $out['svc'][0]['adj'][$j]['group_code']  = 'CR'; // presuming a correction or reversal
  49                 $out['svc'][0]['adj'][$j]['reason_code'] = 'Balancing';
  50                 $out['svc'][0]['adj'][$j]['amount'] = $adjtotal;
  51             }
  52             // if ($out['svc'][0]['code'] != 'Claim') {
  53             //   $out['warnings'] .= "First service item payment amount " .
  54             //   "adjusted by $paytotal due to payment imbalance. " .
  55             //   "This should not happen!\n";
  56             // }
  57         }
  58
  59         $cb($out);
  60     }
  61 }
  62
  63 function parse_era($filename, $cb) {
  64   $delimiter1 = '~';
  65   $delimiter2 = '|';
  66   $delimiter3 = '^';
  67
  68     $infh = fopen($filename, 'r');
  69     if (! $infh) return "ERA input file open failed";
  70
  71     $out = array();
  72     $out['loopid'] = '';
  73     $out['st_segment_count'] = 0;
  74     $buffer = '';
  75     $segid = '';
  76
  77     while (true) {
  78     if (strlen($buffer) < 2048 && ! feof($infh)) $buffer .= fread($infh, 2048);
  79         $tpos = strpos($buffer, $delimiter1);
  80         if ($tpos === false) break;
  81         $inline = substr($buffer, 0, $tpos);
  82         $buffer = substr($buffer, $tpos + 1);
  83
  84     // If this is the ISA segment then figure out what the delimiters are.
  85     if ($segid === '' && substr($inline, 0, 3) === 'ISA') {
  86       $delimiter2 = substr($inline, 3, 1);
  87       $delimiter3 = substr($inline, -1);
  88     }
  89
  90         $seg = explode($delimiter2, $inline);
  91         $segid = $seg[0];
  92
  93         if ($segid == 'ISA') {
  94             if ($out['loopid']) return 'Unexpected ISA segment';
  95             $out['isa_sender_id']      = trim($seg[6]);
  96             $out['isa_receiver_id']    = trim($seg[8]);
  97             $out['isa_control_number'] = trim($seg[13]);
  98             // TBD: clear some stuff if we allow multiple transmission files.
  99         }
 100         else if ($segid == 'GS') {
 101             if ($out['loopid']) return 'Unexpected GS segment';
 102             $out['gs_date'] = trim($seg[4]);
 103             $out['gs_time'] = trim($seg[5]);
 104             $out['gs_control_number'] = trim($seg[6]);
 105         }
 106         else if ($segid == 'ST') {
 107             parse_era_2100($out, $cb);
 108             $out['loopid'] = '';
 109             $out['st_control_number'] = trim($seg[2]);
 110             $out['st_segment_count'] = 0;
 111         }
 112         else if ($segid == 'BPR') {
 113             if ($out['loopid']) return 'Unexpected BPR segment';
 114             $out['check_amount'] = trim($seg[2]);
 115             $out['check_date'] = trim($seg[16]); // yyyymmdd
 116             // TBD: BPR04 is a payment method code.
 117         }
 118         else if ($segid == 'TRN') {
 119             if ($out['loopid']) return 'Unexpected TRN segment';
 120             $out['check_number'] = trim($seg[2]);
 121             $out['payer_tax_id'] = substr($seg[3], 1); // 9 digits
 122             $out['payer_id'] = trim($seg[4]);
 123             // Note: TRN04 further qualifies the paying entity within the
 124             // organization identified by TRN03.
 125         }
 126         else if ($segid == 'REF' && $seg[1] == 'EV') {
 127             if ($out['loopid']) return 'Unexpected REF|EV segment';
 128         }
 129         else if ($segid == 'CUR' && ! $out['loopid']) {
 130             if ($seg[3] && $seg[3] != 1.0) {
 131                 return("We cannot handle foreign currencies!");
 132             }
 133         }
 134         else if ($segid == 'REF' && ! $out['loopid']) {
 135             // ignore
 136         }
 137         else if ($segid == 'DTM' && $seg[1] == '405') {
 138             if ($out['loopid']) return 'Unexpected DTM|405 segment';
 139             $out['production_date'] = trim($seg[2]); // yyyymmdd
 140         }
 141         //
 142         // Loop 1000A is Payer Information.
 143         //
 144         else if ($segid == 'N1' && $seg[1] == 'PR') {
 145             if ($out['loopid']) return 'Unexpected N1|PR segment';
 146             $out['loopid'] = '1000A';
 147             $out['payer_name'] = trim($seg[2]);
 148         }
 149         else if ($segid == 'N3' && $out['loopid'] == '1000A') {
 150             $out['payer_street'] = trim($seg[1]);
 151             // TBD: N302 may exist as an additional address line.
 152         }
 153         else if ($segid == 'N4' && $out['loopid'] == '1000A') {
 154             $out['payer_city']  = trim($seg[1]);
 155             $out['payer_state'] = trim($seg[2]);
 156             $out['payer_zip']   = trim($seg[3]);
 157         }
 158         else if ($segid == 'REF' && $out['loopid'] == '1000A') {
 159             // Other types of REFs may be given to identify the payer, but we
 160             // ignore them.
 161         }
 162         else if ($segid == 'PER' && $out['loopid'] == '1000A') {
 163             // TBD: Report payer contact information as a note.
 164         }
 165         //
 166         // Loop 1000B is Payee Identification.
 167         //
 168         else if ($segid == 'N1' && $seg[1] == 'PE') {
 169             if ($out['loopid'] != '1000A') return 'Unexpected N1|PE segment';
 170             $out['loopid'] = '1000B';
 171             $out['payee_name']   = trim($seg[2]);
 172             $out['payee_tax_id'] = trim($seg[4]);
 173         }
 174         else if ($segid == 'N3' && $out['loopid'] == '1000B') {
 175             $out['payee_street'] = trim($seg[1]);
 176         }
 177         else if ($segid == 'N4' && $out['loopid'] == '1000B') {
 178             $out['payee_city']  = trim($seg[1]);
 179             $out['payee_state'] = trim($seg[2]);
 180             $out['payee_zip']   = trim($seg[3]);
 181         }
 182         else if ($segid == 'REF' && $out['loopid'] == '1000B') {
 183             // Used to report additional ID numbers.  Ignored.
 184         }
 185         //
 186         // Loop 2000 provides for logical grouping of claim payment information.
 187         // LX is required if any CLPs are present, but so far we do not care
 188         // about loop 2000 content.
 189         //
 190         else if ($segid == 'LX') {
 191             if (! $out['loopid']) return 'Unexpected LX segment';
 192             parse_era_2100($out, $cb);
 193             $out['loopid'] = '2000';
 194         }
 195         else if ($segid == 'TS2' && $out['loopid'] == '2000') {
 196             // ignore
 197         }
 198         else if ($segid == 'TS3' && $out['loopid'] == '2000') {
 199             // ignore
 200         }
 201         //
 202         // Loop 2100 is Claim Payment Information. The good stuff begins here.
 203         //
 204         else if ($segid == 'CLP') {
 205             if (! $out['loopid']) return 'Unexpected CLP segment';
 206             parse_era_2100($out, $cb);
 207             $out['loopid'] = '2100';
 208             $out['warnings'] = '';
 209             // Clear some stuff to start the new claim:
 210             $out['subscriber_lname']     = '';
 211             $out['subscriber_fname']     = '';
 212             $out['subscriber_mname']     = '';
 213             $out['subscriber_member_id'] = '';
 214             $out['crossover']=0;
 215             $out['svc'] = array();
 216             //
 217             // This is the poorly-named "Patient Account Number".  For 837p
 218             // it comes from CLM01 which we populated as pid-diagid-procid,
 219             // where diagid and procid are id values from the billing table.
 220             // For HCFA 1500 claims it comes from field 26 which we
 221             // populated with our familiar pid-encounter billing key.
 222             //
 223             // The 835 spec calls this the "provider-assigned claim control
 224             // number" and notes that it is specifically intended for
 225             // identifying the claim in the provider's database.
 226             $out['our_claim_id']      = trim($seg[1]);
 227             //
 228             $out['claim_status_code'] = trim($seg[2]);
 229             $out['amount_charged']    = trim($seg[3]);
 230             $out['amount_approved']   = trim($seg[4]);
 231             $out['amount_patient']    = trim($seg[5]); // pt responsibility, copay + deductible
 232             $out['payer_claim_id']    = trim($seg[7]); // payer's claim number
 233         }
 234         else if ($segid == 'CAS' && $out['loopid'] == '2100') {
 235             // This is a claim-level adjustment and should be unusual.
 236             // Handle it by creating a dummy zero-charge service item and
 237             // then populating the adjustments into it.  See also code in
 238             // parse_era_2100() which will later plug in a payment reversal
 239             // amount that offsets these adjustments.
 240             $i = 0; // if present, the dummy service item will be first.
 241             if (!$out['svc'][$i]) {
 242                 $out['svc'][$i] = array();
 243                 $out['svc'][$i]['code'] = 'Claim';
 244                 $out['svc'][$i]['mod']  = '';
 245                 $out['svc'][$i]['chg']  = '0';
 246                 $out['svc'][$i]['paid'] = '0';
 247                 $out['svc'][$i]['adj']  = array();
 248             }
 249             for ($k = 2; $k < 20; $k += 3) {
 250                 if (!$seg[$k]) break;
 251                 $j = count($out['svc'][$i]['adj']);
 252                 $out['svc'][$i]['adj'][$j] = array();
 253                 $out['svc'][$i]['adj'][$j]['group_code']  = $seg[1];
 254                 $out['svc'][$i]['adj'][$j]['reason_code'] = $seg[$k];
 255                 $out['svc'][$i]['adj'][$j]['amount']      = $seg[$k+1];
 256             }
 257         }
 258         // QC = Patient
 259         else if ($segid == 'NM1' && $seg[1] == 'QC' && $out['loopid'] == '2100') {
 260             $out['patient_lname']     = trim($seg[3]);
 261             $out['patient_fname']     = trim($seg[4]);
 262             $out['patient_mname']     = trim($seg[5]);
 263             $out['patient_member_id'] = trim($seg[9]);
 264         }
 265         // IL = Insured or Subscriber
 266         else if ($segid == 'NM1' && $seg[1] == 'IL' && $out['loopid'] == '2100') {
 267             $out['subscriber_lname']     = trim($seg[3]);
 268             $out['subscriber_fname']     = trim($seg[4]);
 269             $out['subscriber_mname']     = trim($seg[5]);
 270             $out['subscriber_member_id'] = trim($seg[9]);
 271         }
 272         // 82 = Rendering Provider
 273         else if ($segid == 'NM1' && $seg[1] == '82' && $out['loopid'] == '2100') {
 274             $out['provider_lname']     = trim($seg[3]);
 275             $out['provider_fname']     = trim($seg[4]);
 276             $out['provider_mname']     = trim($seg[5]);
 277             $out['provider_member_id'] = trim($seg[9]);
 278         }
 279         else if ($segid == 'NM1' && $seg[1] == 'TT' && $out['loopid'] == '2100') {
 280             $out['crossover']     = 1;//Claim automatic forward case.
 281
 282         }
 283         // 74 = Corrected Insured
 284         // TT = Crossover Carrier (Transfer To another payer)
 285         // PR = Corrected Payer
 286         else if ($segid == 'NM1' && $out['loopid'] == '2100') {
 287             // $out['warnings'] .= "NM1 segment at claim level ignored.\n";
 288         }
 289         else if ($segid == 'MOA' && $out['loopid'] == '2100') {
 290             $out['warnings'] .= "MOA segment at claim level ignored.\n";
 291         }
 292         // REF segments may provide various identifying numbers, where REF02
 293         // indicates the type of number.
 294         else if ($segid == 'REF' && $seg[1] == '1W' && $out['loopid'] == '2100') {
 295             $out['claim_comment'] = trim($seg[2]);
 296         }
 297         else if ($segid == 'REF' && $out['loopid'] == '2100') {
 298             // ignore
 299         }
 300         else if ($segid == 'DTM' && $seg[1] == '050' && $out['loopid'] == '2100') {
 301             $out['claim_date'] = trim($seg[2]); // yyyymmdd
 302         }
 303         // 036 = expiration date of coverage
 304         // 050 = date claim received by payer
 305         // 232 = claim statement period start
 306         // 233 = claim statement period end
 307         else if ($segid == 'DTM' && $out['loopid'] == '2100') {
 308             // ignore?
 309         }
 310         else if ($segid == 'PER' && $out['loopid'] == '2100') {
 311
 312             $out['payer_insurance']  = trim($seg[2]);
 313             $out['warnings'] .= 'Claim contact information: ' .
 314                 $seg[4] . "\n";
 315         }
 316         // For AMT01 see the Amount Qualifier Codes on pages 135-135 of the
 317         // Implementation Guide.  AMT is only good for comments and is not
 318         // part of claim balancing.
 319         else if ($segid == 'AMT' && $out['loopid'] == '2100') {
 320             $out['warnings'] .= "AMT segment at claim level ignored.\n";
 321         }
 322         // For QTY01 see the Quantity Qualifier Codes on pages 137-138 of the
 323         // Implementation Guide.  QTY is only good for comments and is not
 324         // part of claim balancing.
 325         else if ($segid == 'QTY' && $out['loopid'] == '2100') {
 326             $out['warnings'] .= "QTY segment at claim level ignored.\n";
 327         }
 328         //
 329         // Loop 2110 is Service Payment Information.
 330         //
 331         else if ($segid == 'SVC') {
 332             if (! $out['loopid']) return 'Unexpected SVC segment';
 333             $out['loopid'] = '2110';
 334             if ($seg[6]) {
 335                 // SVC06 if present is our original procedure code that they are changing.
 336                 // We will not put their crap in our invoice, but rather log a note and
 337                 // treat it as adjustments to our originally submitted coding.
 338                 $svc = explode($delimiter3, $seg[6]);
 339                 $tmp = explode($delimiter3, $seg[1]);
 340                 $out['warnings'] .= "Payer is restating our procedure " . $svc[1] .
 341                     " as " . $tmp[1] . ".\n";
 342             } else {
 343                 $svc = explode($delimiter3, $seg[1]);
 344             }
 345             if ($svc[0] != 'HC') return 'SVC segment has unexpected qualifier';
 346             // TBD: Other qualifiers are possible; see IG pages 140-141.
 347             $i = count($out['svc']);
 348             $out['svc'][$i] = array();
 349       // It seems some payers append the modifier with no separator!
 350       if (strlen($svc[1]) == 7 && empty($svc[2])) {
 351         $out['svc'][$i]['code'] = substr($svc[1], 0, 5);
 352         $out['svc'][$i]['mod']  = substr($svc[1], 5);
 353       } else {
 354         $out['svc'][$i]['code'] = $svc[1];
 355         $out['svc'][$i]['mod']  = $svc[2] ? $svc[2] . ':' : '';
 356         $out['svc'][$i]['mod']  .= $svc[3] ? $svc[3] . ':' : '';
 357         $out['svc'][$i]['mod']  .= $svc[4] ? $svc[4] . ':' : '';
 358         $out['svc'][$i]['mod']  .= $svc[5] ? $svc[5] . ':' : '';
 359         $out['svc'][$i]['mod'] = preg_replace('/:$/','',$out['svc'][$i]['mod']);
 360       }
 361             $out['svc'][$i]['chg']  = $seg[2];
 362             $out['svc'][$i]['paid'] = $seg[3];
 363             $out['svc'][$i]['adj']  = array();
 364             // Note: SVC05, if present, indicates the paid units of service.
 365             // It defaults to 1.
 366         }
 367         // DTM01 identifies the type of service date:
 368         // 472 = a single date of service
 369         // 150 = service period start
 370         // 151 = service period end
 371         else if ($segid == 'DTM' && $out['loopid'] == '2110') {
 372             $out['dos'] = trim($seg[2]); // yyyymmdd
 373         }
 374         else if ($segid == 'CAS' && $out['loopid'] == '2110') {
 375             $i = count($out['svc']) - 1;
 376             for ($k = 2; $k < 20; $k += 3) {
 377                 if (!$seg[$k]) break;
 378         if ($seg[1] == 'CO' && $seg[$k+1] < 0) {
 379           $out['warnings'] .= "Negative Contractual Obligation adjustment " .
 380             "seems wrong. Inverting, but should be checked!\n";
 381           $seg[$k+1] = 0 - $seg[$k+1];
 382         }
 383                 $j = count($out['svc'][$i]['adj']);
 384                 $out['svc'][$i]['adj'][$j] = array();
 385                 $out['svc'][$i]['adj'][$j]['group_code']  = $seg[1];
 386                 $out['svc'][$i]['adj'][$j]['reason_code'] = $seg[$k];
 387                 $out['svc'][$i]['adj'][$j]['amount']      = $seg[$k+1];
 388                 // Note: $seg[$k+2] is "quantity".  A value here indicates a change to
 389                 // the number of units of service.  We're ignoring that for now.
 390             }
 391         }
 392         else if ($segid == 'REF' && $out['loopid'] == '2110') {
 393             // ignore
 394         }
 395         else if ($segid == 'AMT' && $seg[1] == 'B6' && $out['loopid'] == '2110') {
 396             $i = count($out['svc']) - 1;
 397             $out['svc'][$i]['allowed'] = $seg[2]; // report this amount as a note
 398         }
 399     else if ($segid == 'AMT' && $out['loopid'] == '2110') {
 400       $out['warnings'] .= "$inline at service level ignored.\n";
 401     }
 402         else if ($segid == 'LQ' && $seg[1] == 'HE' && $out['loopid'] == '2110') {
 403             $i = count($out['svc']) - 1;
 404             $out['svc'][$i]['remark'] = $seg[2];
 405         }
 406         else if ($segid == 'QTY' && $out['loopid'] == '2110') {
 407             $out['warnings'] .= "QTY segment at service level ignored.\n";
 408         }
 409         else if ($segid == 'PLB') {
 410             // Provider-level adjustments are a General Ledger thing and should not
 411             // alter the A/R for the claim, so we just report them as notes.
 412             for ($k = 3; $k < 15; $k += 2) {
 413                 if (!$seg[$k]) break;
 414                 $out['warnings'] .= 'PROVIDER LEVEL ADJUSTMENT (not claim-specific): $' .
 415                     sprintf('%.2f', $seg[$k+1]) . " with reason code " . $seg[$k] . "\n";
 416                 // Note: For PLB adjustment reason codes see IG pages 165-170.
 417             }
 418         }
 419         else if ($segid == 'SE') {
 420             parse_era_2100($out, $cb);
 421             $out['loopid'] = '';
 422             if ($out['st_control_number'] != trim($seg[2])) {
 423                 return 'Ending transaction set control number mismatch';
 424             }
 425             if (($out['st_segment_count'] + 1) != trim($seg[1])) {
 426                 return 'Ending transaction set segment count mismatch';
 427             }
 428         }
 429         else if ($segid == 'GE') {
 430             if ($out['loopid']) return 'Unexpected GE segment';
 431             if ($out['gs_control_number'] != trim($seg[2])) {
 432                 return 'Ending functional group control number mismatch';
 433             }
 434         }
 435         else if ($segid == 'IEA') {
 436             if ($out['loopid']) return 'Unexpected IEA segment';
 437             if ($out['isa_control_number'] != trim($seg[2])) {
 438                 return 'Ending interchange control number mismatch';
 439             }
 440         }
 441         else {
 442             return "Unknown or unexpected segment ID $segid";
 443         }
 444
 445         ++$out['st_segment_count'];
 446     }
 447
 448     if ($segid != 'IEA') return 'Premature end of ERA file';
 449     return '';
 450 }
 451 //for getting the check details and provider details
 452 function parse_era_for_check($filename) {
 453   $delimiter1 = '~';
 454   $delimiter2 = '|';
 455   $delimiter3 = '^';
 456
 457     $infh = fopen($filename, 'r');
 458     if (! $infh) return "ERA input file open failed";
 459
 460     $out = array();
 461     $out['loopid'] = '';
 462     $out['st_segment_count'] = 0;
 463     $buffer = '';
 464     $segid = '';
 465     $check_count=0;
 466     while (true) {
 467
 468     if (strlen($buffer) < 2048 && ! feof($infh)) $buffer .= fread($infh, 2048);
 469         $tpos = strpos($buffer, $delimiter1);
 470         if ($tpos === false) break;
 471         $inline = substr($buffer, 0, $tpos);
 472         $buffer = substr($buffer, $tpos + 1);
 473
 474     // If this is the ISA segment then figure out what the delimiters are.
 475     if ($segid === '' && substr($inline, 0, 3) === 'ISA') {
 476       $delimiter2 = substr($inline, 3, 1);
 477       $delimiter3 = substr($inline, -1);
 478     }
 479
 480         $seg = explode($delimiter2, $inline);
 481         $segid = $seg[0];
 482
 483         if ($segid == 'ISA') {
 484
 485         }
 486         else if ($segid == 'BPR') {
 487         ++$check_count;
 488             //if ($out['loopid']) return 'Unexpected BPR segment';
 489             $out['check_amount'.$check_count] = trim($seg[2]);
 490             $out['check_date'.$check_count] = trim($seg[16]); // yyyymmdd
 491             // TBD: BPR04 is a payment method code.
 492
 493         }
 494         else if ($segid == 'N1' && $seg[1] == 'PE') {
 495             //if ($out['loopid'] != '1000A') return 'Unexpected N1|PE segment';
 496             $out['loopid'] = '1000B';
 497             $out['payee_name'.$check_count]   = trim($seg[2]);
 498             $out['payee_tax_id'.$check_count] = trim($seg[4]);
 499
 500         }
 501         else if ($segid == 'TRN') {
 502             //if ($out['loopid']) return 'Unexpected TRN segment';
 503             $out['check_number'.$check_count] = trim($seg[2]);
 504             $out['payer_tax_id'.$check_count] = substr($seg[3], 1); // 9 digits
 505             $out['payer_id'.$check_count] = trim($seg[4]);
 506             // Note: TRN04 further qualifies the paying entity within the
 507             // organization identified by TRN03.
 508         }
 509
 510
 511
 512
 513         ++$out['st_segment_count'];
 514     }
 515     $out['check_count']=$check_count;
 516     era_callback_check($out);
 517
 518     if ($segid != 'IEA') return 'Premature end of ERA file';
 519     return '';
 520     }
 521 ?>